Kyle Murphy, PhD

Findings from a recent EHR usability study conducted by the National Institute of Standards and Technology (NIST) once brought to the fore the problem of clinical documentation in the digital age of healthcare.

The study of EHR use, particularly copy-and-paste functionality, led to three major findings. First, clinicians participating in the study were concerned about EHR data integrity as a result of copying and pasting information. Second, clinicians identified entering the wrong information into the wrong record as a high potential risk. Third, participants reported that over documentation introduced challenges to accessing “accurate, relevant and timely information on a patient” at the point of care.

Despite its intended purpose to improve the ease and efficiency of clinical documentation, NIST concluded that the copy-and-paste functionality “has introduced overwhelming and unintended safety-related issues into the clinical environment.”

Concerns about the accuracy and quality of EHR documentation are nothing new. In a 2013 update to 2007 guidance on EHR documentation integrity, a workgroup convened by the American Health Information Management Association (AHIMA) called for safeguards to ensure electronic documentation did not undermine patient care.

“Without safeguards in place, records could reflect an inaccurate picture of the patient’s condition, either at admission or as it changes over time,” the AHIMA workgroup wrote. “The provider must understand the necessity of reviewing and editing all defaulted data to ensure that only patient-specific data for that visit is recorded, while all other irrelevant data pulled in by the default template is removed.”

What’s more, the authors of the EHR documentation guidance emphasized the urgency of addressing how the use of automated EHR functions could compromise the integrity of clinical health data.

“Data quality and record integrity issues must be addressed now, before widespread deployment of health information exchange (HIE),” they maintained. “Poor data quality will be amplified with HIE if erroneous, incomplete, redundant, or untrustworthy data and records are allowed to cascade across the healthcare system.”